The potential role of plantains, moringa, plantain-moringa combined diets, and other plant-based dietary patterns in controlling glycaemia among T2DM persons, a hospital based cross sectional survey in Ghana

Abstract

Background

Diabetes mellitus (DM) is an independent risk-factor for cardiovascular diseases. Plant-based dietary-patterns have been shown to reverse the effects of these cardiovascular risk-factors. Our study therefore aimed to investigate the potential roles moringa, moringa-plantain combined, and other plant based dietary-patterns could play in controlling glycaemia among persons with type-2-diabetes Mellitus (T2DM).

Methods

Facility-based cross-sectional-study was conducted among 530 T2DM patients from August 2018 to September 2019 in Ghana. Structured-questionnaires were used to collect demographic, anthropometric, and clinical variables. Adherence to plant-based dietary-patterns were assessed using 3-day food record. SPSS version-20 was used to analyse the data.

Results

BMI, HbA1c%, HDL-cholesterol and LDL-cholesterol were significantly correlated with adherence to plant-based dietary-patterns (p-value < 0.05). After adjusting for physical activity, adherence to plantain diets Standardized regression coefficient β (95%CI): -0.098 (-0.321, -0.022), yam β (95%CI): 0.148 (0.066, 0.496), moringa diets β (95%CI): -0.095 (-0.325,-0.011) and bean-diets β (95%CI): -0.112 (-0.577, -0.007) were significantly associated with glycemic control. Adherence to plantain-moriga combined diets β (95%CI): -0.406 (-0.413, -0.049) and plantain-beans combined diets β (95%CI): -0.128 (-0.188, -0.038) were also significantly associated with glycemic control.

Conclusion

Adherence to plantain, yam, beans, plantain-moriga combined diets, and plantain-beans combined diets could be associated with glycemic-control. Health care workers should prioritize these plant-based dietary-patterns for disease prevention and health promotion.

Introduction

Diabetes mellitus (DM) is a global public health problem and an independent risk factor for cardiovascular diseases. People with diabetes have 2–4 times increased risk for heart diseases or stroke compared with those without diabetes [1]. Dietary recommendations with emphasis on plant-based dietary patterns have been highly touted in DM management and prevention. For instance study among Seventh-day Adventists congregants shows that prevalence of type 2 diabetes(T2DM) among persons consuming vegetarian diets is approximately half of those following omnivorous diets [2]. Other studies also show that meat consumption is associated with increased risk of type 2 diabetes [3, 4]. In clinical trial, glycemic control was found improved among persons consuming vegetarian diets [5]. Furthermore, prospective cohort studies among vegetarians, also show that vegetarians eating patterns are associated with lower prevalence of: T2DM [6] cardiovascular disease (CVD) [7] hypertension and obesity [8, 9], and reduced usage of medical care [10], thus suggesting the beneficial effects of plant-based dietary patterns in DM preventing and treating. Other studies also show that individuals who follow plant-based dietary patterns, typically consume fewer calories, more fiber, more potassium and vitamin C, and consumed less: Saturated fat, cholesterol, and have decrease risk for body mass indexes (BMIs) than non-vegetarians [11–13]. Although Plant-based dietary patterns are shown to play significant roles in diseases preventions and body weight management, the question ‘’which plant-based products have the greatest benefits over others for glycemic controls, cardiovascular diseases risk reduction, weight management and other non-communicable diseases’’ preventions and controls continue to remain controversial. This controversy arises because many studies exploring the association of vegetarians or plant-based dietary patterns with diseases prevention and management usually have relatively short durations (< 4 weeks), small sample sizes, and most failed to control the effects of confounding factors on the disease prognosis. This therefore limits the ability of nutrition researchers to strongly draw conclusions on the effect of plant-based dietary patterns in disease prevention and control. Despite these, many studies keep on throwing light on the beneficial effects of vegetarians’ dietary plans on diseases prevention and health promotion purposes.

Moringa and plantain are plant-based products commonly eaten by many people in Africa, most parts of Asia and Southern America. Moringa is a multipurpose plant consumed as food and medicine. The leaves, seeds and pods of this plant are the main parts that are commonly eaten as foods, and are found to have high polyphenol in the form of phenolic acids, flavonoids and glucosinolates. These products are shown to exert numerous in vitro and in vivo effects, including hypoglycemic activity [14]. Moringa plant and its products are known to have many health benefits to human. For instance, extracts from the roots and leaves of moringa have been shown to uplift mood, prevent onset of chronic diseases, and build body immunity to fight against infections [15]. Again, moringa leaves when combined with banana, milk and almond in drinks, is shown to contain high amount of tryptophan which works to uplift mood, and reduce stress [16].

Moringa oleifera, also called the drumstick tree, miracle tree, ben oil tree, or the horseradish tree, has been used many centuries ago due to its medicinal properties and health promotion purposes, particularly in DM management. Apart from the medicinal properties of this plant, it also contains variety of proteins, vitamins, minerals, and other properties such as antifungal, antiviral, antidepressant, and anti-inflammation [17] which are essential for the wellbeing of humans. In Ghana Moringa plants are commonly found growing in people backyard gardens as vegetables or on the field as wild weeds and herbs. Persons who voluntary consumed these plants and their products as foods, are often shown to have better health outcomes when compared with others.

Like the moringa, plantain also have numerous health benefits. Studies show that plantains and bananas help boost body immune system, regulate digestion, and are good sources of potassium and vitamins C [18] to humans. The vitamins C content in plantains acts as natural antioxidants that fight against free radical damaging effect in the body and prevent aging and diseases like cancers, heart diseases and diabetes [18]. Moringa and plantains are very low in calories/sugar, and are essential in DM management. Despite these beneficial effects of moringa and plantain diets, not much is known about their effects in Africa especially in Ghana. Diabetes mellitus is a disease that is very difficult to treat and expensive to manage. Therefore nutrition scientists and researchers are searching for best alternatives to effectively management this disease. Recently the uniform calorie-controlled diet plans used in diabetes management have been replaced with individualized meal-planning approaches [19]. Dieticians therefore need to search for dietary management that would be mutually inclusive to help persons with DM meet their nutritional need and glycemic control goals.

However, the lack of evidence based information about some plant-based dietary products in diseases prevention and management make recommendations of these products in clinical practice much more difficult or problematic. This however, prompted us to conduct this study to investigate whether adherence to plantain, moringa, plantain-moringa combined diets, and other plant based dietary patterns have the potential role to control glycaemia among persons with T2DM in Ghana.

Method

Hospital based cross-sectional survey was conducted among 530 individuals living with DM from August 2018 to September 2019 in Brong Ahafo Region (BAR), Ghana. The sample size for this study was determined using single population proportion formula as described in previously publication [20]

Sampling

We sampled normal weight individuals (BMI 18.5 to 24.9 kg/m2), aged 18 years and above, who were diagnosed of T2DM by physicians based on the American Diabetes Association Diagnostic and Classification Guideline 2011 [21], and counseled to follow recommended dietary guidelines for diabetes, for at least 3 months and over into our study. Participants’ aged 70 years and above who could not answer interview questions, mentally incapacitated, and severely ill were excluded. We also excluded patients with pancreatitis, other liver diseases and pregnant and lactating mothers. Moreover we excluded patients taking nutrients and other plant-based dietary supplements. Participants aged 70 years and above were excluded from our studies because these members generally have conditions such poor fitting dentures, dysphagia, dementia and other medical conditions that generally cause low foods intakes and inappropriate adherence to dietary recommendations. Simple random sampling was used to select 6 hospitals, and the eligible participants were consecutively enrolled through systematic random sampling.

Ethical approval

The study protocol was approved by Ghana Health Service Ethics Review Committee (GHS-ERC008/08/18) and Tehran University of Medical Sciences Ethics Review board (IR.TUMS.VCR.REC.1397.409). All participants were requested to sign an informed consent form before participating in the study. This study was performed in accordance with the Declaration of Helsinki for humans and laboratory animal research.

Assessing demographic, anthropometric and clinical characteristics

Age, diabetes-duration, smoking status, physical activity level, medications intakes, and education level were assessed using structured questionnaires. Weight and height were measured using adult weighing scale and stadiometer, and readings recorded to the nearest 0.5 kg and 0.5 m respectively. These measurements were taken when participants were in light clothes without shoes, and were in standing position. Body mass index (BMI, kg/m2) was calculated by dividing weight in kilograms with square meters height. Systolic and diastolic blood pressures were measured using manual sphygmomanometer and stethoscope, and the reading recorded to the nearest 0.5 mmHg after participants were allowed to relax for 5 or more minutes. Blood samples were taken to assess HbA1c, FBS and other biochemical parameters.

Assessing participants’ dietary intakes, and adherence to moringa, plantain and moringa-plantain combined dietary patterns

Dietary intakes were assessed using 3-day food record. Participants’ were asked to respond to a 3 separate days’ food record questionnaires (one on Monday, Wednesday, and Saturday) to evaluate their true dietary intakes in a typical day. In this questionnaire, participants were asked to report details of all foods and drinks/beverages they took in each day prior to the interview. They were asked to report in detail the foods preparation method, portion size served and the actual amount they ate. The information obtained were summed up and analyzed using Ntri.IV software. For assessing adherence to moringa, plantain and moringa-plantain combined dietary patterns, Perceived Dietary Adherence Questionnaire (PDAQ) for Persons living with T2DM was used [22]. This questionnaire consists of nine items and seven points Likert’s scale ranging from 0 to 7. This questionnaire was designed to elicit information about adherence to dietary recommendations among persons with DM. Participants in our study were asked to report on the Likert’s scale how many times they consumed moringa, plantain, moringa-plantain combined diet and other plant-based diets in a typical week. Participants who reported 0 point to the questionnaire were said to have non-adherence, and those who scored 7 points were said to have the highest adherence. The nine items in the questionnaire were summed up to form global score and represented patients’ total adherence to moringa, plantain, moringa-plantain combined diet and other plant-based dietary pattrerns. Patients’ total adherence score was 63.

Assessing physical activity levels

Participants’ physical activity level was assessed using World Health Organization (WHO) Physical Activity Short Form Questionnaires. The results obtained were grouped with reference to the WHO physical activity guidelines and cut off points (‘’Not meet recommendations; Total Physical Activity’’ MET minutes per week < 600) and ‘’Meet recommendation; Total Physical Activity’’ MET minutes per week ≥ 600) [23]

Laboratory/biochemistry analysis

An overnight (12 h) fasting whole blood sample between 40–60 mL was collected from participants and sent laboratory for the estimation of fasting blood sugar and HbA1c test. HbA1c test was carried out by turbidimetric inhibition immunoassay method using Cobas Integra automated Chemistry analyzer (Roche Cobas Integra 400 Plus, Roche Diagnostics, USA) [24]. Participants’ overnight fasting blood samples were collected in EDTA test tubes to prevent cross reaction prior to analysis. The well-mixed EDTA-anti-coagulated whole blood was later transferred into sample test-tubes and placed on a rack. The red blood cells in the test tubes were hemolyzed using low osmotic pressure and the free hemoglobin degraded with pepsin to liberate the N-terminal of beta chain (β-N-terminal) of the HbA1c. The HbA1c β-N-terminal was then bind with latex particles-bound monoclonal antibodies while the remaining free antibodies were agglutinated using synthetic polymers. This process formed multiple copies of β-N-terminal structure of HbA1c, and therefore leave the test sample turbid in the test tube. The change in turbidity of the sample was then measured at 552 nm and the final HbA1c values were expressed as a percentage using the formula:

$$\mathrm{HbA}1\mathrm{c}(\%)=\left(\frac{\mathrm{HbA}1\mathrm{c}}{\mathrm{Hb}}\right)\times 100$$

Participants with fasting blood sugar (FBS) 7.0 mmol/l and above, or HbA1c value of 6.5% and above were said to have diabetes.

The test was standardized with an intra-assay coefficient of variation (CVs) 0.9–1.5% and inter-assay CVs 1.1–1.6%. Daily calibrations and maintenance of the analyzer were performed according to the manufacturer’s instructions [25]. Quality control was maintained using the quality control procedures provided with the analyzer by the manufacturer [negative and positive controls (high and low HbA1c)]. Other biochemical parameters such as low-density lipoprotein cholesterol (LDL-C), high-density lipoprotein cholesterol (HDL-C), triglycerides (TG), total cholesterol (TC), serum bicarbonate, serum creatinine (Cr) and blood urea nitrogen (BUN) were obtained from participants’ past two to three months medical records in the hospital.

Statistical analysis

IBM SPSS version 20.0 (SPSS, Chicago, IL, USA) was used in data analysis. Data normal distributions were checked with Kolmogorov–Smirnov test. Descriptive statistics were used to describe participants’ demographic characteristics, while Pearson correlation tests used to test correlation between demographic, anthropometry and clinical variables with adherence to plant-based dietary patterns. Finally multiple linear regression models were used to assess the association of adherence to plant-based dietary patterns and glycemic control. Multiple linear regression model looks at the association between predictor variables on one dependent variable in an equation Y = a + b₁X₁ + b₂X₂ + _b3X₃ + b₄X₄ + b₅X₅ + b_kX_k + e, where ‘a’ is the regression constant, b is the regression coefficient, X₁…….X_k are the independent variables and ‘e’ is the variance of the population mean distributions. This statistic was used in our study because our dependent variable (Adherence to plant-based dietary pattern) is normally distributed and has equal variance around the mean. The independent variables also have linear relationships with no multicollinearity. Furthermore, our sample size is fairly large and is said to have fair representation of the larger population which met the assumption for the statistics used. We set all variables statistical significant at 0.050 alpha levels in our analysis.

Results

Participants’ demographic characteristics and clinical variables were presented in Table 1. Mean and standard deviation of age, duration lived with DM and adherence to plant-based dietary patterns were 58.10(9.70), 4.90(5.39) and 32.56(9.61) respectively. Majority (70.9%) of the participants were female, have: no education (38.1%), junior high (24.9%) and university education (3.0%). Mean and standard deviation of systolic and diastolic blood pressure were 135.67(20.44) and 77.79 (12.79) respectively. Mean and standard deviation of HbA1c%, Triglyceride, HDL-cholesterol and LDL-cholesterol were 8.12(3.34), 4.63(14.14), 1.73(0.90) and 5.15(3.40) respectively.

Table 1.

Participants demographic and clinical variables

Demographic Variables	N (%)	Means(SD)
Age (years)		58.10(9.70)
Duration lived with Diabetes (years)		4.90(5.39)
BMI(Kg/m2)		23.14(2.92)
Number of cigarette smoke per day		0.16(0.49)
Physical Activity ( Metabolic equivalent)		2843.16(3956.39)
Adherence to plant-based dietary patterns		32.56(9.61)
Sex
Male	154(29.1)
Female	376(70.9)
Medication intakes
Yes	413(77.9)
No	117(22.1)
Educational Level
No education	202(38.1)
Primary	85(16.0)
High	132(24.9)
Senior High	67(12.6)
Training College	21(4.0)
Polytechnic	10(1.9)
University	13(2.5)
Clinical Variables
Systolic blood pressure (mmHg)		135.67(20.44)
Diastolic blood pressure (mmHg)		77.79 (12.79)
HbA1c%		8.12(3.34)
Fasting Blood Sugar(mmol/L)		10.05(4.55)
Total cholesterol (mmol/L)		7.18(3.48)
Triglycerides(mmol/L)		4.63(14.14)
HDL-C (mmol/L)		1.73(0.90)
LDL-C (mmol/L)		5.15(3.40)
Total Bilirubin (mg/dL)		19.69(16.41)

N (%), Number (percentage); Means (SD), Mean ± Standard deviation; BMI, Body mass index; HbA1c%, Glycated hemoglobin; HDL-C, High density lipoprotein cholesterol; LDL-C, Low density lipoprotein cholesterol

Table 2 presented the correlation of participants’ demographic characteristics and clinical variables with adherence to plant-based dietary pattern. Significant correlation was found between BMI, HbA1c%, HDL-cholesterol and LDL-cholesterol with adherence to plant-based dietary pattern (p-value < 0.05).

Table 2.

Correlation of demographic characteristics and clinical variable with adherence to plant-based dietary patterns

Variables	Adherence to plant-based dietary patterns (r)	p-value
BMI(Kg/m2)	0.087*	0.045
Systolic blood pressure (mmHg)	-0.025	0.568
Diastolic blood pressure (mmHg)	0.054	0.213
Diabetes duration (years)	0.045	0.296
Age (years)	-0.050	0.255
Education level	0.049	0.262
Physical Activity	-0.035	0.422
Number of cigarette smoke per day	-0.045	0.305
HbA1c%	-0.279**	< 0.001
Fasting blood sugar(mmol/L)	-0.219**	< 0.001
Total cholesterol(mmol/L)	-0.107*	0.014
Triglycerides (mmol/L)	0.019	0.668
HDL-C (mmol/L)	-0.091*	0.035
LDL-C (mmol/L)	-0.105*	0.015
Total Bilirubin	-0.052	0.232

(r) correlation coefficient **p-value < 0.001, *p-value < 0.05

BMI, Body mass index; HbA1c%, Glycated hemoglobin; HDL-C, High density lipoprotein cholesterol; LDL-C, Low density lipoprotein cholesterol

The potential role of plantain, moriga, plantain-moringa combined diets and other plant-based dietary patterns in controlling glycaemia are presented in Table 3. Statistically significant associations were found for adherence to plantain diets, Standardized regression coefficient β (95%CI): -0.098 (-0.321, -0.022), yam diets β (95%CI): 0.148 (0.066, 0.496), moringa leaves diets β (95%CI): -0.095 (-0.325,-0.011) and bean diets β(95%CI): -0.112 (-0.577-0.007) with glycemic control. Furthermore, significant associations were found for plantain-moriga combined diet β (95%CI): -0.406 (-0.413, -0.049) and plantain-beans stew combined diet β (95%CI): -0.128 (-0.188, -0.038) with glycemic control.

Table 3.

The potential role of plantain, moringa, and plantain-moringa combined diets in controlling glycaemia

Variables	Unstandardized regression coefficient(β)	Standard error	Standardized regression coefficient(β)	t	P-value	95%CI
Plantain Adj	-0.171	0.076	-0.098	-2.248	0.025	-0.321, -0.022
Yam Adj	0.281	0.109	0.148	2.572	0.011	0.066, 0.496
Egg Plant Stew Adj	0.030	0.038	0.036	0.784	0.433	-0.045, 0.105
Moringa leaves Adj	-0.168	0.080	-0.095	-2.097	0.036	-0.325, -0.011
Bean Stew Adj	-0.292	0.145	-0.112	-2.013	0.045	-0.577, -0.007
Cucumber Adj	-0.112	0.262	-0.048	-0.428	0.670	-0.633, 0.409
Groundnut Past Adj	-0.001	0.002	-0.023	-0.525	0.600	-0.005, 0.003
Roasted Groundnut Adj	-0.004	0.004	-0.071	-1.004	0.316	-0.012, 0.004
Plantain*Egg Plant diet Adj	0.014	0.034	0.047	0.419	0.677	-0.053, 0.081
Plantain*Moriga diet Adj	-0.231	0.091	-0.406	-2.529	0.013	-0.413, -0.049
Plantain*Beans Stew Adj	-0.113	0.038	-0.128	-2.949	0.003	-0.188, -0.038
Yam*Moriga diet Adj	-0.134	0.129	-0.045	-1.039	0.299	-0.388, 0.120

95%CI, 95% confidence interval; Adj, Adjusted for the effect of physical activity; Plantain*Moriga diet, lantain and Moriga diets combination; Plantain*Egg Plant diet, Plantain and Eggplant diets combination; Yam*Moriga diet, Yam and Moringa diet combination, Plantain*Beans, Plantain and Beans combination

Discussions

Many studies have touted the benefits of plant-based dietary patterns in health promotion and disease prevention [26–28]. In line with this, we also waded into the discussions to throw more light on the beneficial effect of plantain, moringa and plantain-moringa combine diets in DM management. The first objective of our study was to establish whether significant correlations exist for participants’ demographic characteristics, anthropometric and clinical variables with adherence to these plant-based dietary patterns. Secondly we sought to establish whether adherence to Moringa, Plantain, Moringa-Plantains combined diets and other plant-based dietary patterns have the potential role to control glycaemia among persons with T2DM. At the end of the study we found that significant correlations exist for BMI (Kg/m²), HbA1c%, Total-cholesterol (mmol/L), HDL-C (mmol/L) and LDL-C (mmol/L) with adherence to plant-based dietary patterns. We also found that significant associations exist between adherences to plantain, yam, moringa, Beans, plantain-moriga combined diets, and plantain-beans combined diets with glycemic control among persons with T2DM which are consistent with other studies [29, 30].

Maintaining glycemic control in diabetes is necessary to prevent many complications and mortality. Although different hypoglycemic drugs are used for this purpose, there is still a growing interest in the use of medicinal plants in DM management due to their low price, easy availability, and fewer or no side effects. Moringa (Moringa oleifera) is a medicinal plant that has been traditionally used in DM management. Many Epidemiological studies have presented evidences on the beneficial effects of these plant-based dietary patterns in DM management and health promotion purposes [31, 32]. These evidences together with other empirical observations have led both the American Association of Nutrition and Dietetics (AAND) and the American Diabetes Association (ADA) to make landmark recommendation for the inclusion of plant-based dietary patterns in meal-planning for persons with diabetes [33, 34].

In our study we noticed that adherence to plantain diets were significant with glycemic control. Persons with T2DM who intake more plantain diets were shown to have decrease risk of glycaemia. This finding could be true because plantains (Musa paradisiaca) are known to have: Low glycemic index (GI), high fiber and resistant starch [35]. These dietary properties of plantain makes it slow in releasing glucose into the blood, and thus negatively affects blood glucose level after consumption. Plantain is a staple crop in the humid and sub-humid parts of Africa, Asia, Central and South America that is usually eaten as energy yielding food [36]. In most folktale medicine, plantain has been used in the management of diabetes, renal and liver dysfunction [37]. The high fibers and resistant starch content of plantain diet makes it good in DM management, and also helps in digestion by adding bulkiness to food in the gastrointestinal tract [38]. The bulkiness effect of fiber in plantain makes individuals consumed few foods with fewer calories, and feel full faster after consuming these diets, and thus help individuals control excess weight gain. With this properties in plantain, it can be said that plantain diets have the potential role to decrease glycaemia, and excess weight gains. Although we have not found any clinical trial showing the significant effects of plantain diets in diabetes management on human beings, studies among laboratory animals demonstrate some significant associations between consuming plantain diets and glycemic control [39–41]. These finding therefore support our results.

In our study, we also investigated the association between yams intake and glycemic control among persons with DM. Yam is one of the staple food that is widely consumed by many people in Ghana. In this study we realized that participants who report increase yams intakes, positively have increased risk of glycaemia. These finding could also be true but quite contradictory because yam has been shown to have high carbohydrates and fiber content with relative low glycemic index value (54) [42]. These dietary properties of yam make it suitable for weight management and diabetes control. However, our results show otherwise. The contradictory findings in our study may be due to variation in the amount of yam consumed, the type of yam consumed and the populations used in conducting the study. Our study used Ghanaians and other studies used persons in other countries. The yam preparation method before consumption could account for the differences in our results with other studies findings.

Moving further, we investigated to see whether adherence to moringa and beans diets could be related with glycemic control. At the end we noticed that adherence to moringa and beans diets significantly improve glycaemia (decreased HbA1c %) among participants. These findings too could be true because beans and moringa (Moringa oleifera) also have low glycemic indexes [43]. In an invivo study to evaluate the effects of moringa oleifera on glycemic control, it is shown that moringa leaf and powder could significantly improve glycemia. This study therefore concluded that moringa oleifera could be a hypoglycemic agent [29] which is consistent with our results.

Since moringa, plantains, and beans diets all independently improve glycaemia in the univariate analysis of our study, we wanted to test whether combining these foods in certain form could significantly improve glycaemia in persons with DM. To our amazement, we found that moringa-plantain combined diets and plantain-beans combined diets significantly improved glycaemia (decreased HbA1c %). These findings are interesting, because our initial expectation has been confirmed. Studies in different countries have highlighted the effects of moringa, plantains and beans in glycemic control [44, 45]. However, with the effect of some confounding variables, the acceptability of the protective effects of these plant-based diets in DM management has been challenged. Although our study sought to address some of these challenges, by controlling some confounding variable, some limitations still exist in our study which make it difficult for us to draw definite conclusions on the effects of these plant-based dietary patterns (moringa, plantain and other plant-based foods) in DM management.

Limitation

Some of the limitations that challenged our conclusion are; our study used relatively small sample size (530 participants) with very low power to detect true associations. Furthermore, we adopted a relatively weak study design (cross sectional study design) to investigate this problem which makes it difficult to detect causal associations. Again we did not determine an upper cut-off point or range for FBS and HbA1c in our study, and because of this we could not establish the exact extent to which moringa, plantain, moringa-plantain combined diets and other plant-based dietary patterns could influence glycemic control. Despite these limitations, our study however demonstrates that controlling the effect of physical activity; moringa, plantain, moringa-plantain combined diets and other plant-based dietary patterns could stand out as candidate in glycemic control among persons with T2DM.

Conclusion

Our study demonstrated that intake of plantain, yam, bean, and plantain-moriga combined diets and plantain-beans combined diets could be significantly associated with glycemic control among persons with T2DM. These evidences therefore suggest that health care workers should prioritized plant-based dietary patterns with more emphasis on plantains, moringa, beans, plantain-moringa combined diets and plantain-beans combined diets in diseases prevention and health promotion purposes.

Authors’ contribution

BDD collected and analyzed the data and wrote the manuscript.

AA obtained ethical clearance in Ghana for this study, supervised the data collection, and proofread the final version of the manuscript before submission.

YM supervised the data analysis and proofread the final version before submission.

SE proofread the final version of the manuscript before submission.

AD acquired funding for the study, supervised the data collection process, and proofread the final version of the manuscript before submission.

MK supervised, coordinated the study, took part in the data collection took p art in the data analysis and wrote the manuscript.

Funding

This study was funded by Tehran University of Medical Sciences.

Data Availability

The datasets generated and/or analyzed during the current study are not publicly available but are available from the corresponding author on reasonable request.

Declarations

Ethical approval

This study protocol was approved by Ghana Health Service Ethics Review Committee (GHS-ERC008/08/18) and Tehran University of Medical Sciences Ethics Review board (IR.TUMS.VCR.REC.1397.409).

Consent for publication

Not applicable.

Competing interests

All authors declare no conflict of interest in this study.